Please note: In my book, Rosacea 101, I wrote a chapter on demodex mites and rosacea and you can read this chapter in my book entitled "Demodectic Rosacea - A Rosacea Variant" on page 28. I have listed in Appendix K - Research Articles on Demodex and Rosacea on page 189 a comprehensive list of pubMed and other articles on demodex and rosacea.

Rosacea 101 is a comprehensive, 373 page book, covering the conventional and alternative treatments for rosacea and covers basic rosacea 101 knowledge for rosacea newbies. It is a must have book for those who need in one book what they need to know about rosacea. Below is some information which helped formed the basis for my discussion on demodectic rosacea.

"While Demodex folliculorum -- a microscopic mite that normally inhabits human skin -- has been found in greater numbers in those with rosacea, it has been long debated whether it may be a cause or simply a result of rosacea. It now appears that its true connection with rosacea's signs and symptoms may be linked to a distinct bacterium associated with the mites, called Bacillus oleronius. In a study funded by the NRS, Dr. Kevin Kavanagh and colleagues at the National University of Ireland-Maynooth found that B. oleronius stimulated an inflammatory response in 79 percent of study patients with subtype 2 (papulopustular) rosacea." Rosacea Review, Fall 2010, NRS-Funded Studies Advance Knowledge of Rosacea's Causes

I want to propose a new rosacea variant - Demodectic Rosacea since if you look at the list of rosacea subtypes and variants it is not even mentioned. Mind-boggling isn't it? Yet research grants have been going on for years studying Demodex Folliculorum in Rosacea. Why hasn't anyone done this? Well, I just did. And this isn't something new. I have found research papers connecting demodex folliculorum with rosacea going back to 1932! Since so much research mentions either demodex mites or demodicosis with rosacea, at the very least, Demodectic Rosacea should be listed as a variant of rosacea. Apparently I am not the first one to propose this. A paper written by Samuel Ayres, Jr., M.D. in 1963 proposed a similar term 'rosacea-like demodicidosis,' and I quote the article for your reading pleasure here:

"As early as 1932 Ayres and Anderson called attention to a type of rosacea which they felt was caused in large part by extraordinarily heavy infestation by the mite, Demodex folliculorum, and it was pointed out that the demodex type of rosacea was a further development or complication of an entity that had been described and named by the present author two years previously under the title 'Pityriasis Folliculorum (Demodex) .' Since that time a number of publications have appeared on the subject as well as an exhibit at the thirteenth annual meeting of the American Academy of Dermatology and Syphilology in 1954....

Demodex folliculorum

...A more recent publication concerning the pathogenic role of Demodex in the production of pityriasis folliculorum (Demodex) and acne rosacea was Ayres and Ayres' summary of 30 years' experience with these two commonly unrecognized entities. Both conditions were referred to as demodicidosis. Inasmuch as the authors' attempts to describe and segregate a particular type of acne rosacea as being caused wholly or in large part by Demodex has led to confusion and to the erroneous statement that the authors have claimed that all cases of rosacea are caused by Demodex, it was felt that a new term should be coined and that rosacea of the Demodex type should henceforth be referred to as 'rosacea-like demodicidosis.' " California Medicine, June 1963 source

I am not the one who came up with the term, Demodectic Rosacea. It was due to an email I received from Gerg Plewig, M.D. which you can read about at this link. I was trying to understand why demodicosis has never been listed as a variant or subtype of rosacea and finally got a response explaining how Demodectic Rosacea is the preferred term. I am still attempting to understand if this is a variant of rosacea or not from the professionals in the RRDi MAC. This is a slow process, but I am patient. Dr. Plewig explained that demodicosis is a skin disease all on its own. According to Dr. Plewig, it is only when demodex mites are in increased numbers on pre-existing rosacea that the term demodectic rosacea is used.

“In other words, which came first: the mites or the rosacea?” study author Frank Powell, M.D., consultant dermatologist at Mater Misericordiae Hospital in Dublin, Ireland, was quoted as saying. “And now there is evidence that it might be the mites." Source

Powell wrote in his book, "Another theory of pathogenesis relates to the presence of abundant Demodex folliculorum mites in the facial skin of patients with rosacea. These small worm-like organisms are inhabitants of the sebaceous follicles of normal adult facial skin. They were first described in the 1800s, but their role in the homeostasis of facial skin is unknown. They have been reported to transport bacteria on the skin surface, and the population can increase markedly in certain circumstances. They can be easily extracted from the follicles where they are found, often in groups, head downward, feeding on sebaceous material. They have eight short subby legs with claw-like end processes, which they use to move about the facial skin surface from one follicle to another. This apparently occurs at night (it has been shown that the mites react negatively to light.) These organisms seem to live in a harmnious relationship with their hosts and in normal circumstances do not excite an inflammatory reaction in the skin. It is not known if they perform any useful function in human skin, and it is probably impossible to fully eradicate them as the skin seems to become recolonized rapidly following antimite treatment. In patients with rosacea, these mites are greatly increased in number and are found mainly in the centrofacial convexities--the areas typically affected by the inflammatory papules and pustules. Histologic sections of inflammatory lesions show the pathologic changes to be centered on the follicles and mites or the fragments of disrupted mites are often seen in the follicular canals surrounded by inflammatory cells. Sometimes ruptured follicles are seen with particles of demodex mites extruded into the dermis. In these cases foreign body granuloma formation to the follicular aeration and/or the mite is a feature of the histopatholgic changes. Immunosuppressed patients (with HIV infection or on immunosuppressive therapy or patients having renal dialysis) or those who have applied immune-modulating drugs (topical steroids/cacineurin inhibitors) to the face may also have increased numbers of demodex mites on the skin. This suggests a possible role of local immune mechanisms restricting the demodex population in normal facial skin. Some immunosuppressed patients may also develop a pustular eruption similar to rosacea with multiple mites identified not only on skin biopsies, but also visualized by microscopic examination of the scale obtained by gently scraping the skin surface. In some individuals these eruptions were cleared when antimite treatment was used. Finally, it has been shown that these mites have related bacteria, some of which are susceptible to the antibiotics used to treat the papules and pustules of rosacea. These facts could explain the effectiveness of topical and systemic antibiotics in the management of this disorder." Rosacea Diagnosis and Management by Frank C. Powell, pages 69, 70

In Chapter 5, on page 75 of Powell's book under the subheading, 'Differential Diagnosis and Investigations,' Powell writes, "These patients have also been shown to have a major increase in the demodex mite count on their facial skin using the cyanoacrylate skin biopsy technique." In discussing Pityriasis folliculorum on pages 81-2 he writes, "The diagnosis of pityriasis folliculorum is facilitated by the use of dermatoscopy, which shows a distinctive picture of the presence of multiple white keratotic material consisting of keratin encrusted demodex mites protruding upwards from the follicular orifices. Scraping the skin surface with the blunt side of a scalpel blade and spreading the scrapings on a glass slide reveals the presence of multiple dead and living D. folliculorum mites. The condition appears to be caused by an overpopulation of mites facilitated by the frequent use of creams and the lack of face washing with soap and water."

He then states on page 82:

"There is no laboratory test or investigation that will confirm the diagnosis of PPR. Specific investigations may be required to rule out similar appearing conditions (many of which will be identified by listening carefully to the patient's medical history and examining the skin lesions). These include skin swabs for bacterial culture, skin scrapings for the presence of demodex mites, scrapings for fungal KOH and fungal culture, skin biopsy for histological examination, (and rarely culture) skin surface biopsy for demodex mite quantification, patch tests, photopatch tests and very rarely systemic workup with appropriate blood tests and radiological examinations."

Demodex folliculorum

If more rosaceans were tested for demodex the data collected would help determine how many rosaceans have this problem. One paper discusses how to test for demodex:

It has been generally understood that "demodicoses are thought to be rare, occurring mainly for patients with immunosuppression." However, a study released in January 2005 had the objective "to demonstrate the high frequency of demodicoses and the overlapping with papulopustular rosacea (PPR) ." What did the study reveal?

"RESULTS: In all, 4372 diagnoses, in which 115 were demodicoses, were collected among 3213 patients. Demodicosis was the 9th most frequent diagnosis (13th new). Each dermatologist observed an average of 2.4 demodicoses a week (1.2 new). The proportion of demodicoses varied greatly according to the dermatologist. The general status was good in 110 patients; only 3 had known immunodeficiency. The most frequent symptoms were follicular scales (71%) and telangiectasia (63%). The mean Dd was higher in pityriasis folliculorum (m = 61 D/cm 2 ) than in PPR (m = 36 D/cm 2 ; P = .04); 42 patients with PPR had a high Dd, 6 had a low Dd. CONCLUSION: Demodicoses are frequent and occur among patients who are immunocompetent. PPR with normal Dd are rare." Jan 2005 source

One report in August 2005 says, "Although there are several clinical variants of this disease, a clear classification is missing." The report further says: "We suggest that demodicosis be divided into both primary and secondary types." source

In 2005 one study concluded that "MMP-9 may be a further explanatory link between the presence of D. folliculorum and the clinical expression of certain cases of rosacea." Journal of the European Academy of Dermatology & Venereology, Volume 19 Issue 5 Page 646 - September 2005 source

Geoffrey Nase, Ph.D., says that "Now there is "real" evidence, so I support a role of demodex, their bacteria and lipase in the aggravation of some rosacea symptoms; NOT the cause, but one aggravating factor. I did not support this four years ago because the science and clinical studies did not support this role." He further states that "several excellent studies have been performed using state-of-the-art biomedical research to show a cause and effect of demodex, their passenger bacteria, and the irritating enzyme, lipase." "Recent studies have clearly shown that demodex mites and their accompanying bacteria and lipase production can exacerbate rosacea..." source

"...Although Demodex mites do not seem to be the cause of rosacea, they may represent an important cofactor, especially in papulopustular rosacea. Immunohistochemical findings suggest that a delayed hypersensitivity reaction, possibly triggered by antigens of follicular origin, probably related to D. folliculorum, may occur, stimulating progression of the affection to the papulopustular stage..." September 2001 source

"...Although usually considered a non-pathogenic parasite in parasitological textbooks, Demodex folliculorum has been implicated as a causative agent for some dermatological conditions, such as rosacea-like eruptions and some types of blepharitis. Several anecdotal reports have demonstrated unequivocal tissue damage directly related to the presence of the parasite..." May/June 2000 source

While there is evidence that demodicosis is a "condition distinct from common rosacea," further research should be done to determine whether to classify demodicosis as variant of rosacea. March/April 2004 source

One report says since oral metronidazole was used to treat demodicosis without results and topical crotamiton was successful in clearing demodicosis that this was evidence demodicosis is a different condition distinct from rosacea. The report concluded: "This observation provides further evidence that demodicidosis is a condition distinct from common rosacea." April/May 1998 source

However, this should be further investigated since there is now evidence that oral metronidazole does indeed help demodicosis. A report in 2003 states: "Oral metronidazole seems to work in the management of this chronic mite infestation." November 2003 source

Another report in 2004 said: "The daily topical application of 1/3 diluted camphor oil with glycerol and 500 mg metronidazole orally were given for fifteen days. The results were very successful with no clinical side effects." This was in a Demodex folliculorum infestation. source

In one report, Demodicidosis revisited, states that demodex "have been identified and have been implied to play a role in at least three facial conditions: pityriasis folliculorum, rosacea-like demodicidosis and so-called "demodicidosis gravis." 2002 source

"Diseases of seborrhoic origin include rosacea, acne, gram-negative folliculitis, demodex-folliculorum, perioral dermatitis as well as seborrhoic dermatitis. An important prerequisite for adequate therapy is the knowledge of these different diseases." source

It has been suggested that demodicosis is a disease that effects primarily people in developing countries and is not prevalent in developed countries. However, since it is simple to test for demodex density and there has been clinically proven results for treating demodicosis rosaceans should insist for tests for demodex to rule out this factor. Demodicosis has been found in developed countries.

Demodex Folliculorum is the name of a type of mite, while Demodex Brevis is another type. Demodicosis is the name of the disease or conditon. I am merely proposing that demodicosis be listed as a variant of rosacea. No one knows what the cause of rosacea is (more info). However, research papers continue to list demodex folliculorum as one of the possible factors in rosacea. A typical paper says the following:

"The cause of rosacea remains somewhat of a mystery. Several hypotheses have been documented in the literature and include potential roles for vascular abnormalities, dermal matrix degeneration, environmental factors, and microorganisms such as Demodex folliculorum and Helicobacter pylori." 2004 source

Whatever criteria is used to determine rosacea demodicosis could be used to add this is the list of variants of rosacea. What I have been told is that a clinical test is administered to check the mite density by a microscopic examination. My understanding is that whatever is the underlying cause, the demodex factor is an aggravating element and has been the focus of many rosacea research grants for years. One of the variants of rosacea is Steriod-Induced. Steroids don't cause rosacea but surely aggravates the conditon, hence is classified as a variant. Why not Demodicosis? Whatever of the cause, there should be some mention of demodicosis in the list of variants since it keeps coming up in clinical studies or whenever the subject of rosacea is discussed.

"The features of demodecidosis are often similar to those of rosacea." May 2005 source

An expert committee assembled by the National Rosacea Society explicitly defined and classified rosacea in April 2002 into 4 different subtypes based upon specific clinical signs and symptoms. This was an important step in the treatment of rosacea. Currently, the therapeutics of rosacea empirically target the signs and symptoms of the disease because investigators do not understand the details of its pathophysiology. Therefore, this classification system aides clinicians in treatment by highlighting the preponderance of one or more of the clustering signs of presentation and, thus, helps to specify which therapeutic approach to initiate.

The diagnosis of rosacea is a clinical diagnosis. Skin biopsy may be necessary to exclude other disease states that mimic the clinical presentation of rosacea. For example, the clinician must exclude polycythemia vera, connective tissue diseases (eg, lupus erythematous, dermatomyositis, mixed connective tissue disease), photosensitivity, carcinoid mastocytosis, long-term application of topical steroids, contact dermatitis, and photosensitivity before making the diagnosis of rosacea. Rosacea is defined by persistent erythema of the central portion of the face lasting for at least 3 months. Supporting criteria include flushing, papules, pustules, and telangiectasias on the convex surfaces. Secondary characteristics are burning and stinging, edema, plaques, a dry appearance, ocular manifestations, and phymatous changes. The prevalence of these findings designates the subclassification of the presentation and, additionally, the therapeutic options."
source >http://www.emedicine.com/derm/topic377.htm

This same article says further down the page,

"Microbial organisms

Demodex species (mites that normally inhabit human hair follicles) may play a role in the pathogenesis of rosacea. Support suggests that Demodex prefers skin regions that are affected in rosacea, such as the nose and cheeks. Studies also support that an immune response of helper-inducer T cell infiltrates occurs, surrounding the Demodex antigens in patients with rosacea. Yet, conflicting evidence indicates that Demodex does not induce an inflammatory response in patients with rosacea. Moreover, Demodex is found in large numbers of healthy individuals without rosacea. More studies need to be performed to determine whether Demodex truly is pathogenic."

Statements like the above keep appearing in rosacea articles and papers and I am only proposing that either a variant or subtype be listed along with the others that includes demodex. The secondary characteristics should also include findings on demodex so that, as it says above, "the prevalence of these findings [including demodex findings] designates the subclassification of the presentation and, additionally, the therapeutic options." As I have repeated, it could be classified as a variant of rosacea.

For years the medical researchers have been studying demodex folliculorum and rosacea, yet have said that the demodex mite plays only a small part in the etiology of rosacea. Hence, the treatments offered for rosacea rarely took into account the demodex mite. However, due to continuing research on this subject demodicosis should be recognized as a variant of rosacea. Why this has been neglected is only conjecture. I hope this editorial will at least get the attention of some rosaceans even if the medical community continues to play down the demodex factor in rosacea.

There is evidence of a relationship between Demodex and bacteria infection in rosacea. Feb. 2004 source

"The presence of Demodex folliculorum is important in the inflammatory reaction, whether it is pathogenetic or not." 2002 source

Fresh skin scrapings viewed under a microscope can reveal the mites which feed on dead cells and skin fats.

However, there are 'limitations of standardized skin surface biopsy in measurement of the density of Demodex folliculorum,' whatever that means? 1998 source

The prevalence of this mite in people with rosacea has been recorded as significantly higher than people without rosacea:

• an infestation of 51% in rosacea;
• an infestation of 28% in eczema;
• an infestation of 31% in lupus discoides. [source]

The following report is of interest:

"A leading theory suggests a vascular basis; however, clinical observations and histopathologic studies suggest that inflammation of the pilosebaceous follicle may be central to the pathogenesis of rosacea. Demodex folliculorum is a frequently seen commensal in the follicles of facial skin. According to evidence from biopsies of the skin surface, individuals with rosacea have a higher density of this parasite. This increased mite density may play a role in the pathophysiology of rosacea by triggering inflammatory or specific immune reactions, mechanically blocking the follicles, or acting as a vector for bacteria. Ongoing research has shown that bacteria from patients with rosacea may behave differently at the higher skin temperature that may be present in patients with rosacea. Another group has isolated bacteria from the Demodex mites; these bacteria may play a pathogenic role in papulopustular rosacea by facilitating follicular-based inflammatory changes." 2004 source

"Conclusions Antigenic proteins related to a bacterium (B. oleronius), isolated from a D. folliculorum mite, have the potential to stimulate an inflammatory response in patients with papulopustular rosacea." source

"Demodex species (mites that normally inhabit human hair follicles) may play a role in the pathogenesis of rosacea. Support suggests that Demodex prefers skin regions that are affected in rosacea, such as the nose and cheeks. Studies also support that an immune response of helper-inducer T cell infiltrates occurs, surrounding the Demodex antigens in patients with rosacea. Yet, conflicting evidence indicates that Demodex does not induce an inflammatory response in patients with rosacea. Moreover, Demodex is found in large numbers of healthy individuals without rosacea. More studies need to be performed to determine whether Demodex truly is pathogenic." source

"A total of 197 patients (117 with rosacea, 29 with akne vulgaris, and 51 with allergic diseases) were examined using the standardized skin surface biopsy (SSSB) and 97 out of 197 (49.23%) cases were found to be positive..." source

"Could the effects of antibiotics in rosacea be caused by their actions on intracellular bacteria of Demodex, rather than to a postulated anti-inflammatory mechanism? We believe so, and will demonstrate this in a first-of-its-kind poster." Source >

"This indicates that the Bacillus bacteria found in the Demodex mite produce an antigen that could be responsible for the tissue inflammation associated with papulopustular rosacea," Dr. Kavanagh said.
The researchers located the bacteria in Demodex folliculorum, which are normal inhabitants of human skin. Because these microorganisms often occur in much greater numbers in patients with rosacea, researchers have long theorized that they may play a part in the development of the disorder." source

In 2005 the NRS paid a grant of $23,600 for rosacea research to study among other items and access "the size of the oil glands and the presence of Demodex mites, normal inhabitants of human skin that have been observed in greater numbers in rosacea patients." source

Dr. Kevin Kavanagh was awarded $25,000 from the NRS to pursue further research on the potential role of bacterial antigens in papulopustular (subtype 2) rosacea. In an earlier NRS-funded study, he and his colleagues succeeded in isolating a bacterium from Demodex folliculorum, microscopic mites that are a common inhabitant of facial skin. The bacteria produced antigens that induced an inflammatory response in significantly more rosacea patients than controls. In the new study, they will determine whether the presence of the antigens is predictive of the onset of rosacea, in order to establish whether they play a significant role. source

The NRS awarded $22,500 to Drs. Kavanagh and Powell to expand on an earlier study involving Demodex mites. They will examine whether these bacteria produce antigens that may cause papules and pustules in rosacea patients. The report said, "This indicates that the Bacillus bacteria found in the Demodex mite produce an antigen that could be responsible for the tissue inflammation associated with papulopustular rosacea," Dr. Kavanagh said.

The researchers located the bacteria in Demodex folliculorum, which are normal inhabitants of human skin. Because these microorganisms often occur in much greater numbers in patients with rosacea, researchers have long theorized that they may play a part in the development of the disorder.

The researchers offered several possibilities that may explain how Demodex and bacteria interact to cause inflammation in rosacea. The Demodex mites may carry the pathogenic bacteria into areas of the face susceptible to the changes of rosacea, so that the increased mite density in rosacea patients may result in a higher density of bacteria that produce the papules and pustules. Alternatively, Demodex mites may be attracted to an area of facial skin rich in these bacteria and increase in numbers in this "fertile territory."

Another possibility is that the mites in rosacea patients are infected with these bacteria, which in turn produce stimulatory antigens that trigger the disorder in susceptible patients." source

The NRS also awarded a grant in 2002 that said "The researchers were awarded $12,250 to test Demodex from rosacea patients for the presence of bacteria, and analyze data for a possible statistical or clinical link between the bacteria and the presence of rosacea. They hypothesize that the cutaneous changes of rosacea may be due to an inflammatory response to bacteria within Demodex rather than the mite itself." source

The NRS awarded $24,700 to Dr. Kavanagh to study whether bacteria associated with the Demodex mite may trigger the disorder directly by their presence or indirectly by stimulating the immune system. source

A Canadian physician, Annette Anderson, B.A., M.D., posted a treatment for her rosacea using Kwellada shampoo, Kwellada lotion (5% Permethrin), and Sulfacet face cream or equivalent antibiotic cream at r-s. She wanted testers to fill in questionnaires, and said she hoped to publish a summary of results in a GP's magazine and you can read about this by clicking here. An RS member named Rachelle (P & Ps, broken blood vessels) tried the treatment and wasn't happy. In addition to a slight flare, she had a break-out that took four days to control, aggravation to her seb derm, and the anti-mite spray severely irritated her sinuses. The doctor apologised but said the problem might be that Rachelle had seb derm as well as rosacea. Also, Rachelle was highly sensitive. Rachelle then posted a list of gentler treatments to kill mites: taking Olive Leaf Extract, and using soap, cream and shampoo containing Tea Tree Oil. The doctor said "natural treatments are always preferable" and left the group the very next day.

"...On the basis of histological, immunological and therapeutic arguments, it has been postulated that D. folliculorum was involved in the pathogenesis of rosacea, notably in its granulomatous form. In particular, several cases of granuloma containing the acarid in its core have been reported. However, the significance of such findings remains uncertain..." source

1984:

"...The predominance of helper-inducer T-cell subsets in the dermal infiltrates of acne rosacea lesions in frequent association with Demodex supports the hypothesis that a cell-mediated immune response plays an important role in the pathogenesis of rosacea..." source

"...In 20 patients with rosacea and rosacea-like eruptions Demodex folliculorum mites were found in high numbers within lesional skin..." source

1980:

This paper spoke about 'the role of Demodex mites in the pathogenesis of rosacea.' source

1976:

Demodecidosis and rosaceiform dermatitis: "The authors refer those dermatoses called "Rosacea like" or "Rosaceiform Dermatitis" that always offer differential diagnosis with Rosacea." source

1974

"This increased mite density may play a role in the pathophysiology of rosacea by triggering inflammatory or specific immune reactions, mechanically blocking the follicles, or acting as a vector for bacteria. Ongoing research has shown that bacteria from patients with rosacea may behave differently at the higher skin temperature that may be present in patients with rosacea." source

"Rosacea-like demodicidosis is an entity resembling acne rosacea which is caused by infestation with an abnormally large number of the mite Demodex folliculorum, usually in association with improper cleansing of the face." source

The first research paper I read about this subject that interested me said in April 1997 which struck me the most:

"...Light and scanning electron microscopy revealed that all mites were pointing in one direction. Some of them were containing bacteria inside their gut and on their skin. After treatment 3 cases (18.75%) were completely cured, 10 cases (62.5%) gave moderate response while 3 cases (18.75) have no response. In conclusion, this study supports the pathogenic role of D. folliculorum in rosacea. (see article below)

I have always envisioned these little mites all standing at attention saluting some higher authority in doing their little dirty work on my face!

"Undoubtedly, infestation with D. folliculorum particularly in large number causes rosacea." source

"Our results suggest that Demodex mites may play a role in the inflammatory reaction in acne rosacea." source

According to jashbotanicals.com, "Apparently Demodex can arrive in adolescence, and by late to middle age all almost all people harbor the Demodex mite to some degree. Researchers say that in people up to 20 years of age, the incidence was about 25%; in people up to 50 years of age, the incidence was 30%; in people up to 80 years of age, the incidence was 50%; and in those aged 90 or older, everyone has it."

Apparently the Chinese have known about the demodex mite for some time and Professor Zhao Zhongzhou has been working on a medicine to eliminate the little creatures which is reported to help rosaceans. (see article below) Professor Zhao Zhongzhou says, "That means 130 million Chinese people are suffering from acarodermatitis  30 million of them have red noses.

You may be interested in some clinical reports on the Zhongzhou cream.

Another paper in June 1998 said,

"We suggest that a certain mite density is not an appropriate criterion in the diagnosis of the disease; nevertheless, large numbers of D. folliculorum may have an important role in the pathogenesis of rosacea, together with other triggering factors." source

These 'other triggering factors' may be an immune system dysfunction according to this study,

"It seems likely that Demodex infestation does not manifest unless local or systemic immune function is altered, leading to the proliferation of the organism and subsequent disease." source

"...infestations with Demodex folliculorum and environmental stimuli are considered to be involved in the inflammatory process...These results indicate that MNA(+) might be a useful agent for treating rosacea." source

It is still not clearly established what is causing rosacea but the evidence is pointing to something that is either bacterial, a fungus, a parasite, or demodex mites going amuck. These demodex mites are on everyone including non-rosaceans, but why are studies of rosaceans revealing these peculiar oddities like 'mites all pointing in one direction' with 'bacteria in their gut and on their skin' and this important statement:

"This indicates that the Bacillus bacteria found in the Demodex mite produce an antigen that could be responsible for the tissue inflammation associated with papulopustular rosacea," source

"For this reason, we suggest that it is useful to test for D. folliculorum in patients with non-classical presentations like facial itching, itching accompanied by non-specific erythema, itching and non-specific pityriasiform squamous lesions, and acneiform lesions." - source

Is there a test that doctors can perform for demodex folliculorum on your face? Answer. Dr. Nase even suggests that in some rosaceans it would be good to test for demodex. source

Can you perform your own self test with a microscope? In my book, Rosacea 101, Appendex H, page 179, there is information on how to perfom your own examination using a microscope.

"D. folliculorum was sought in the lesion sites using the non-invasive method known as the Standardised Skin Surface Biopsy (SSSB)." source

Treatment of rosacea-like demodicidosis with oral ivermectin and topical permethrin cream has been reported to help. source

And why would this statement be made if demodex folliculorum isn't a factor in the pathogenesis of rosacea?

... Oral Ivermectin (Stromectol) is making a huge difference in these [rosacea] sufferers facial symptoms and flushing triggers (yes, I said flushing triggers). Ivermectin is an anti-mite drug that is related to the macrolide antibiotics. It has a very good safety profile and less side effects than most antibiotics (and not one major side effect)..." source

And why would a double blind, placebo controlled clinical study be done on rosaceans taking Stromectol if demodex isn't considered a factor in rosacea? check this out

The above source mentions some recent unpublished clinical studies. These unpublished clinical studies now add weight to the clinical studies done in Turkey and elsewhere that are mentioned in this editorial. Obviously, these types of clinical studies are trying to uncover the relationship of the pathogenesis of demodex folliculorum's role to rosacea. Unless more research is done on finding the cause of rosacea and studies on what treatments work best we will never know. That is why I have founded the Rosacea Research and Development Insitute.

T.J. Dunn, DVM, says, in discussing whether demodex mites can be transferred from a pet to a human:

"...Human demodex cases do occur but transmission from the dog to a human is quite rare. Nevertheless, human cases of demodex do happen where transmission from a family pet to a human occurs. See a case of demodex in a human below.) The mites reside and feed in the hair follicle and oil glands of the skin. Also called Mange, which is a general term used to describe any kind of mite infestation,..."

The above article supplies photos of a woman with a dermal infestation of demodex on her face and it looks very much like rosacea. You may view these photos by clicking here which is also the source of the above quote.

Why mention that "Permethrin 5% cream is superior to metronidazole 0.75% gel and placebo in decreasing Demodex folliculorum, and is as effective as metronidazole 0.75% gel in treating erythema and papules..." in treating rosacea if demodex folliculorum is not a significant role player in rosacea? source

"The effect of permethrin 5% cream on D. folliculorum was superior to that of metronidazole 0.75% gel." source

Prescription Drugs

According to one report, "topical Elimite (permethrin, Allergan), topical Eurax
(crotamiton, Ranbaxy) or systemic ivermectin" prescription drugs can be used to treat demodex.

Camphor Oil

Topical Camphor oiland oral metronidazole has been clinically effective in the treatment of demodicosis. source

Treatment of human Demodex folliculorum by camphor oil and metronidazole.
J Egypt Soc Parasitol. 2004 Apr;34(1):107-16.
A total of 15 females suffering from erythematotelangiectatic rosacea and 12 females free from other dermatological lesions were selected. Demodex folliculorum infestation density in both patients and control were evaluated by non-invasive skin surface biopsies. Five facial sites were selected. The daily topical application of 1/3 diluted camphor oil with glycerol and 500 mg metronidazole orally were given for fifteen days. The results were very successful with no clinical side effects. source

Oil of Oregano

It has been reported that oil of oregano has been used to treat rosacea by possibly eliminating the mites. For more information click here.

"...the highest density of mites was found on the cheeks. A statistically significant increase in mites was found in all subgroups of rosacea, being most marked in those with steroid-induced rosacea...CONCLUSION: Increased mites may play a part in the pathogenesis of rosacea by provoking inflammatory or allergic reactions, by mechanical blockage of follicles, or by acting as vectors for microorganisms.source

"...Lower quantities of lipids determined a higher incidence of Demodex folliculorum in rosacea patients. Demodex folliculorum were also more frequently detected in patients who had previously been treated with topical corticosteroids (even in 91.9%), what was often followed by epitheloid granulomas..." source

"Rosacea is not an infectious disease, and there is no evidence that it can be spread by contact with the skin or through inhaling airborne bacteria. However, there has long been a theory that parasites in the hair follicles or oil glands or the face can stimulate inflammation by their activity or even their presence. One such organism is the Demodex folliculorum mite, which studies have shown to be more prevalent and active in rosacea patients then in control groups. Early vascular and connective tissue changes probably create a favorable setting for a growth of Demodex folliculorum. This may represent an important cofactor especially in papulopustular rosacea, in which a delayed hypersensitivity reaction is suspected, but it is not the cause of rosacea. On the other hand, clearing rosacea signs after oral tetracycline or sulfur ointment may not affect the resident demodex population." source

A random sample of 16 female patients suffering from papulopustular rosacea (PPR) as well as (16) normal female healthy subjects as control group were adopted in this study to assess of Demodex folliculorum pathogenesis. It was done through determination of mite density using a standard skin surface biopsy 10.5 cm2 from different designated 6 areas on the face, and scanning electron microscopic study (SEM) as well as total IgE estimation. A trial of treatment using Crotamiton 10% cream with special program was also attempted. All subjects ranged between 35-55 years old. All patients with rosacea and 15 of the control group i.e. 75.93% were found to harbour mites. The mean mite counts by site distribution were 28.6 & 6.9 on the cheeks, followed by 14.5 & 3.0 on the forehead and lastly 6.8 & 0.8 on the chin in PPR and control groups respectively. The total mean mite count in patients was 49.9 initially and 7.9 after treatment. In the control group it was 10.7 & 10.6 respectively. The mean total IgE was 169.4 & 168.4 and 96.3 & 98.4 in PPR and control groups respectively Light and scanning electron microscopy revealed that all mites were pointing in one direction. Some of them were containing bacteria inside their gut and on their skin. After treatment 3 cases (18.75%) were completely cured, 10 cases (62.5%) gave moderate response while 3 cases (18.75) have no response. In conclusion, this study supports the pathogenic role of D. folliculorum in rosacea.

BACKGROUND: Demodex folliculorum has been reported in rosacea in a number of clinical studies. As the Demodex mite is also present in many healthy individuals, it has been suggested that the mite may have a pathogenic role only when it is present in high densities. Moreover, some authors have proposed that a mite density above 5/cm2 may be a criterion for the diagnosis of inflammatory rosacea. In this study, the possible role of D. folliculorum and the importance of mite density in rosacea were investigated using a skin surface biopsy technique. METHODS: Thirty-eight patients with rosacea and 38 age-and-sex-matched healthy subjects entered the study. With the skin surface biopsy technique, we obtained samples from three facial sites. We then determined the mite positivities, the mean mite counts in both study groups, the mean mite densities at each facial site and in the rosacea subgroups, and the mite densities above 5/cm2. RESULTS: The mean mite count in the rosacea group (6,684) was significantly higher than that in controls (2,868; p < 0.05). The cheek was the most frequently and heavily infested facial region. Ten rosacea patients and five normal subjects had mite densities over 5/cm2; the difference was not statistically significant (p > 0.05). CONCLUSIONS: Rosacea is a disease of multifactorial origin, and individual properties may modify the severity of the inflammatory response to Demodex. We suggest that a certain mite density is not an appropriate criterion in the diagnosis of the disease; nevertheless, large numbers of D. folliculorum may have an important role in the pathogenesis of rosacea, together with other triggering factors.

Researchers have successfully demonstrated a possible role for bacteria associated with microscopic mites in the development of subtype 2 (papulopustular) rosacea, which is characterized by persistent redness with bumps (papules) and pimples (pustules). Many researchers have postulated that rosacea is a vascular disorder but mounting evidence suggests otherwise. The most significant statement of the research says,

"This indicates that the Bacillus bacteria found in the Demodex mite produce an antigen that could be responsible for the tissue inflammation associated with papulopustular rosacea,"

According to this report, there is "a new anti-demodex cream with 2% metronidazole. There have been various versions out there for quite a while..... most of them causing irritation and without results. I am intrigued by this new cream that has shown almost complete erradication of demodex after 3 to 4 months of use (via biopsy). You can purchase this online (OTC)....The Xin Fumanling cream is a medicated cream.
It contains:
3% Metronidazole
Radix Angelicae Dahuricae
Radix Stemonae
And other herbs."Source

Zhao Zhongzhou’s Ointment for Acne Rosacea

A topical treatment for rosacea has been in use for some time in China developed by Professor Zhao Zhongzhou.

Zhao Zhongzhou, 67, has 40 years experience as a surgeon, initially in the People’s Liberation Army, then in a hospital as an enterprise, he invented Zhongzhou Ointment and is now the chairman of the board of directors of Kunming Zhongzhou Pharmaceutical Corporation Limited, based in Kunming , capital of southwest China’s Yunnan Province .

With an invention patent granted by China’s State Patent Office, the ointment wiped acne off the faces of 93.46 % of 107 patients who took part in a clinical test in 1985-86.

Department of Dermatology and Allergology, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.
We present a 35-year-old patient with acquired immunodeficiency syndrome who had demodicidosis on his face, characterized by multiple papules and papulopustules, associated pruritus, numerous mites on skin-surface biopsy and in biopsy specimens, and rapid response to topical treatment with permethrin. It seems likely that Demodex infestation does not manifest unless local or systemic immune function is altered, leading to the proliferation of the organism and subsequent disease.
source > http://www.ncbi.nlm.nih.gov:

Ronald Boender reports an anecdotal report of a cure for rosacea by "washing my eyelids with Johnson's baby shampoo twice a day with very hot washcloths" and has "been cured for 6 years now and threw away my tetracycline." Ronald says he "read about Demodex folliculorum on the web and realized this was probably my cause of rosacea." source